Lenguajes descriptivos

Outpatient Prescription Drug Benefits shall be provided if You, while covered under this Certificate, incur an expense for Prescription Drugs which were prescribed by any Physician who is either a Preferred Provider or Out- of-Network Provider. You are responsible for the applicable Deductible, Copayment or Coinsurance, as shown in the "Schedule of Benefits" section of this Certificate.

Prescription Drugs must be dispensed for a condition, illness or injury that is covered by this Plan. Refer to the "General Limitations and Exclusions" section of this Certificate to find out if a particular condition is not covered. Coverage includes disposable devices that are Medically Necessary for the administration of a covered outpatient Prescription Drug.

Tier I Drugs (Generic Drugs excluding Specialty Drugs) and Tier II Drugs (Preferred Brand Name Drugs)

Prescription Drugs listed in the Health Net Essential Rx Drug List are covered, when prescribed by a Physician, an authorized referral Specialist or an emergent or urgent care Physician. Some Tier I and Tier II Drugs require Prior Authorization from HNL to be covered. The fact that a drug is listed in the Essential Rx Drug List does not guarantee that Your Physician will prescribe it for You for a particular medical condition.

Tier III Drugs

Tier III Drugs are Prescription Drugs that non-preferred Brand Name Drugs, Brand Name Drugs with generic equivalent (when Medically Necessary), drugs listed as Tier III Drugs in the Essential Rx Drug List or drugs not listed in the Essential Rx Drug List.

Some Prescription Drugs that are not on the Essential Rx Drug List require Prior Authorization from HNL to be covered.

Specialty Drugs

Specialty Drugs listed in the Health Net Essential Rx Drug List are covered when Prior Authorization is obtained from HNL and the drugs are dispensed through HNL’s Specialty Pharmacy Vendor. These drugs include self- administered injectable and other drugs that have significantly higher cost than traditional pharmacy benefit drugs. Please note that needles and syringes required to administer the self-injected medications are covered only when obtained through the Specialty Pharmacy Vendor.

Self-administered injectable medications are defined as drugs that are:  Medically Necessary;

 Administered by the patient or family member; either subcutaneously or intramuscularly;

 Deemed safe for self-administration as determined by Health Net’s Pharmacy and Therapeutics Committee;  Included in the Health Net Essential Rx Drug List; and

 Shown on the Essential Rx Drug List as requiring Prior Authorization.

Certain specified specialty drugs or drugs with limited distribution must be obtained through a contracted specialty pharmacy. These specified specialty drugs that must be obtained through the Specialty Pharmacy Program are limited up to a 30-day supply. The Specialty Pharmacy Program will deliver your medication to you by mail or common carrier. These drugs are subject to the applicable Copayments or Coinsurances listed under "Outpatient Prescription Drugs" in the "Schedule of Benefits."

If you are out of a specialty drug which must be obtained through the specialty pharmacy program, HNL will authorize an override of the specialty pharmacy program requirement for 72-hours, or until the next business day following a holiday or weekend, to allow you to get an emergency supply of medication if your doctor decides that it is appropriate and medically necessary. You may have to pay the applicable Copayment.

Generic Equivalents to Brand Name Drugs

When a Medically Necessary Brand Name Drug is dispensed has an equivalent generic drug, You are financially responsible for the Tier III Drug Copayment, as shown in the "Schedule of Benefits" section of this Certificate.

Off-Label Drugs

A Prescription Drug prescribed for a use that is not stated in the indications and usage information published by the manufacturer is covered only if the drug meets all of the following coverage criteria:

1. The drug is approved by the Food and Drug Administration; AND 2. The drug meets one of the following conditions:

A. The drug is prescribed by a participating licensed health care professional for the treatment of a life- threatening condition; OR

B. The drug is prescribed by a participating licensed health care professional for the treatment of a chronic and seriously debilitating condition, the drug is Medically Necessary to treat such condition and the drug is either on the Essential Rx Drug List or Prior Authorization by HNL has been obtained; AND

3. The drug is recognized for treatment of the life-threatening or chronic and seriously debilitating condition by one of the following:

A. The American Hospital Formulary Service Drug Information; OR

B. One of the following compendia, if recognized by the federal Centers for Medicare and Medicaid Services as part of an anticancer therapeutic regimen:

i. The Elsevier Gold Standard’s Clinical Pharmacology.

ii. The National Comprehensive Cancer Network Drug and Biologics Compendium. iii. The Thomson Micromedex DrugDex; OR

C. Two articles from major peer reviewed medical journals that present data supporting the proposed off- label use or uses as generally safe and effective unless there is clear and convincing contradictory evidence presented in a major peer reviewed medical journal.

The following definitions apply to the terms mentioned in this provision only. "Life-threatening" means either or both of the following:

A. Diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted;

B. Diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival.

"Chronic and seriously debilitating" refers to diseases or conditions that require ongoing treatment to maintain remission or prevent deterioration and cause significant long-term morbidity.

Any coverage required for Off-Label Drugs shall also include Medically Necessary services associated with the administration of a drug, subject to the conditions of the Certificate.

Diabetic Drugs and Supplies

Prescription Drugs for the treatment of diabetes (including insulin) are covered as stated in the Essential Rx Drug List. Diabetic supplies are also covered, including, but not limited to, specific brands of pen delivery systems, specific brands of disposable insulin needles and syringes, disposable insulin pen needles, specific brands of blood glucose monitors and test strips (specific brand only); Ketone test strips; lancet puncture devices and lancets when used in monitoring blood glucose levels. Additional supplies are covered under the medical benefit; please refer to the "Diabetic Equipment" provision above in this section; please refer to the "Schedule of Benefits" section for details about the supply amounts that are covered at the applicable Copayment.

Preventive Drugs and Women’s Contraceptives

Preventive drugs, including smoking cessation drugs, and women’s contraceptives are covered as shown in the "Schedule of Benefits" section of this Certificate. Covered preventive drugs are over-the-counter drugs or Prescription Drugs that are used for preventive health purposes per the U.S. Preventive Services Task Force A and B recommendations.

Covered contraceptives are FDA-approved contraceptives for women that are either available over-the-counter or are only available with a Prescription Drug Order. Women’s contraceptives that are covered under this

Prescription Drug benefit include vaginal, oral, transdermal and emergency contraceptives. For a complete list of contraceptive products covered under the Prescription Drug benefit, please refer to the Essential Rx Drug List. Over-the-counter preventive drugs and women’s contraceptives that are covered under this Plan require a Prescription Drug Order. You must present the Prescription Drug Order at a Health Net Participating Pharmacy to obtain such drugs or contraceptives.

Intrauterine devices (IUDs), injectable and implantable contraceptives are covered as a medical benefit when administered by a Physician. Please refer to the "Preventive Care Services" and "Family Planning" provisions in this section for information regarding contraceptives covered under the medical benefit

.

Smoking Cessation Coverage

Over-the-counter drugs and drugs on the Essential Rx Drug List that require a prescription in order to be dispensed by a retail pharmacy for the relief of nicotine withdrawal symptoms are covered.

Smoking cessation programs are covered by HNL. For information regarding smoking cessation behavioral modification support programs available through HNL, contact the Customer Contact Center at the telephone number on Your HNL ID Card or visit Our website at www.healthnet.com (see “Wellsite”).

Compounded Drugs

Compounded Drugs are prescription orders that have at least one ingredient that is Federal Legend or state restricted in a therapeutic amount as Medically Necessary and are combined or manufactured by the pharmacist and placed in an ointment, capsule, tablet, solution, suppository, cream or other form and require a prescription order for dispensing. Compounded Drugs (that use FDA approved drugs for an FDA approved indication) are covered if at least one of the main ingredients is on the Essential Rx Drug List. Refer to the "Off-Label Drugs" provision in this section for information about FDA approved drugs for off-label use. Coverage for Compounded Drugs requires the Tier III Drug Copayment and is subject to Prior Authorization by HNL and Medical Necessity.